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Neurologic Assessment: Rhenier S. Ilado RN
Neurologic Assessment: Rhenier S. Ilado RN
ASSESSMENT
Rhenier S. Ilado RN.
Learning Objectives:
After the presentation, we should be able to:
• Perform a physical assessment of the
neurologic system
• Document neurologic system findings
• Differentiate between normal and abnormal
findings
INTRODUCTION
• The human nervous system is a unique system that allows
the body to interact with the environment as well as to
maintain the activities of internal organs.
• The nervous system acts as the main “circuit board” for
every body system. Because the nervous system works so
closely with every other system, a problem within
another system or within the nervous system itself can
cause the nervous system to “short-circuit.”
(Dillon,2007)
• A major goal of nursing is early detection to
prevent or slow the progression of disease.
• So it is important for nurses to accurately perform a
thorough neurologic assessment and to understand
the implications of subtle changes in assessment
findings. By doing so, we can initiate timely
interventions that can save lives.
(Dillon,2007)
REVIEW OF THE
ANATOMY AND PHYSIOLOGY
OF THE
NEUROLOGIC SYSTEM
Cont. Review of Ana and Physio
Schwann
cell
nucleus
synapse
Synaptic
vesicles
Axon
Myelin
Presynaptic
terminal
Receptors Postsynaptic
Synaptic
in skin membrene
cleft
Neurotransmitter
Postsynaptic
substance
receptor
Neuromuscular
junction
Neurons band together into
- peripheral nerves,
- spinal nerves,
- spinal cord, and
- tissues of the brain.
pons
medulla Posterior column
Fine touch, proprioception
Lateral spinothalamic tract
and vibration
Pain &temperature
Anterior spinothalamic tract
Crude touch & pressure Posterior root
of the spinal
cord
Spinal cord
Motor Pathways
• Motor pathways (descending or efferent) transmit impulses from the brain to the
muscles
Motor Cortex
Trunk, Arm, Hand,
Leg Fingers, Face, Lips,
Knee Tongue
Foot
toes
Skeletal
muscles
Reflex arc
PERIPHERAL NERVOUS SYSTEM
Normal: Abnormal:
Spontaneous ■ Impaired spontaneous speech: -
speech intact. Cognitive impairment.
Impaired motor speech (dysarthria):
Motor speech
Problem with CN XII
intact.
c. Autonomic Speech
Have patient say something that is committed
to memory, such as days of week or months of
year.
Normal: Abnormal:
■ Automatic ■ Impaired automatic speech:
speech intact. Cognitive impairment or
memory problem.
4. LEVEL OF CONSCIOUSNESS
Normal: Abnormal:
Awake, alert, and Disorientation may be physical in
oriented to time, origin
place, and person Disorientation can also be
(AAO x 3) psychiatric in origin
(schizophrenia)
Responds to
Lathargic or somnolent
external stimuli
Obtunded
Stupor
Coma
Glasgow Coma Scale
- A standardized objective assessment that
defines the LOC by giving it a numeric value.
- Most often after brain surgery
- Document as E_V_M_; for example, E4V5M6.
GLASGOW COMA SCALE
Eyes open ■ Spontaneously . . . . . . . . 4 Findings
E ■ To command . . . . . . . . . . 3
■ To pain . . . . . . . . . . . . . . . 2
■ Unresponsive. .. . . . . . . . . 1
Best verbal ■ Oriented . . . . . . . . . . . . . . . 5 Findings
response ■ Confused . . . . . . . . . . . . . . . 4
V ■ Inappropriate . . . . . . . . . . . . 3
■ Incomprehensible . . . . . . . . 2
■ Unresponsive. . . . . . . . . .. . . 1
MOTOR
RESPONSE
4 Thumbs up, fist, or peace sign to command
3 Localizing to pain
2 Flexion response to pain
1 Extensor posturing
0 No response to pain or generalized myoclonus status epilepticus
BRAINSTEM
REFLEXES
4 Pupil and corneal reflexes present
3 One pupil wide and fixed
2 Pupil or corneal reflexes absent
1 Pupil and corneal reflexes absent
0 Absent pupil, corneal, and cough reflex
RESPIRATION
4 Not intubated, regular breathing pattern
3 Not intubated, Cheyne-Stokes breathing pattern
2 Not intubated, irregular breathing pattern
1 Breathes above ventilator rate
0 Breathes at ventilator rate or apnea
5. MEMORY
a. Test immediate recall:
Ask patient to repeat three numbers, such as “4, 9, 1.” If
patient can do so, ask her or him to repeat a series of five
digits.
b. Test recent memory:
Ask what patient had for breakfast.
c. Test long-term memory:
Ask patient to state his or her birthplace, recite his or he
Social Security number, or identify a culturally specific
person or event, such as the name of the previous president of
the United States or the location of a natural disaster.
Normal: Abnormal:
Memory problems can be benign
Immediate, recent,
or signal a more
and remote serious neurologic problem
memory intact. - such as Alzheimer’s disease.
Forgetfulness - especially for
immediate and recent events
- often in older adults.
- With benign forgetfulness,
person can retrace or use memory
aids to help with recall.
Pathological memory loss
- as inAlzheimer’s disease
Cont. Abnormal:
Temporary memory loss
- may occur after head trauma.
Retrograde amnesia
- for events just preceding illness or
injury.
Postconcussion syndrome
- can occur 2 weeks to 2 months
after injury and may cause short-
term memory deficits.
6. COGNITIVE FUNCTION
a. Mathematical and Calculative Ability
Ask patient to perform a simple calculation, such as adding 4
x 4. If successful, proceed to more difficult calculation, such as 11 9.
Normal: Abnormal:
Mathematical/calculative Inability to calculate at level
ability intact and appropriate appropriate to age,
for patient’s age, educational education, and language ability
level, and language facility. requires evaluation for neurologic
impairment.
b. General Knowledge and Vocabulary
Ask how many days in a week and months in a year.
c. Thought Process
Ask patient to define familiar words such as “apple,”
“earthquake,” and “chastise.”
Begin with easy words and proceed to more difficult
ones.
Remember to consider the patient’s age, educational
level, and cultural background.
Normal: Abnormal:
Thought Incoherent speech
illogical or unrealistic ideas
process intact repetition of words and phrases
repeatedly straying from topic
suddenly losing train of thought (examples of
altered thought processes that indicate need for
further evaluation)
Normal: Abnormal:
Able to generalize from specific
example and apply statement to
■ Impaired ability to think
human behavior. abstractly:
Children should be able - Dementia, delirium, mental
to distinguish like from unlike as retardation, psychoses.
appropriate for theirage and
language facility.
e. Judgment
Observe patient’s response to current situation.
Ask patient to respond to a situation or
hypothetical situation.
Normal: Abnormal:
Judgment ■ Impaired judgment can be
appropriate and associated with dementia,
intact. psychosis, or drug and alcohol
abuse.
Assessing the CRANIAL NERVES
1. CN I—Olfactory Nerve
a. Before testing nerve function, ensure
patency of each nostril by occluding in
turn and asking patient to sniff.
b. Once patency is established, ask
patient to close
eyes.
c. Occlude one nostril and hold aromatic
substance
such as coffee beneath nose.
d. Ask patient to identify
substance.
e. Repeat with other nostril.
Normal: Abnormal:
■ Patient is able to ■ Anosmia is loss of sense of smell.
identify substance. -May be inherited and
nonpathological: chronic rhinitis,
(Bear in mind that sinusitis, heavy smoking, zinc
some substances may be deficiency, or cocaine use.
unfamiliar, especially to - It may also indicate cranial nerve
damage from facial fractures or head
children.)
injuries, disorders of base of frontal
lobe such as a tumor, or
artherosclerotic changes.
- Persons with anosmia usually also
have taste problems.
2. CNs II, III, IV, and VI—Optic, Oculomotor,
Trochlear, and Abducens Nerves
Testing CN V – sensory
function
c. Testing corneal reflex:
- Gently touch cornea with cotton wisp.
o Touching cornea can cause abrasions. Alternative approach
is to:
> puff air across cornea with a needless
syringe, or
> gently touch eyelash and look for blink reflex.
Normal: Abnormal:
Full range of motion Weak or absent contraction unilaterally:
- Lesion of nerve, cervical spine, or
(ROM) in jaw and 15
brainstem.
strength.
Inability to perceive light touch and
Patient perceives light superficial pain
touch and superficial pain - may indicate peripheral nerve damage.
bilaterally. ■ Tic douloureux:
- Neuralgic pain of CN V caused by the
pressure of degeneration of a nerve.
■ Corneal reflex test used in patients with
decreased LOC
- to evaluate integrity of brainstem.
4. CN VII—Facial Nerve
a. Testing motor function:
- Ask patient to perform these movements: smile, frown, raise
eyebrows, show upper teeth, show lower teeth, puff out cheeks,
purse lips, close eyes tightly while nurse tries to open them.
Sweet:
Tip of the tongue
Sour:
Sides of back half of
tongue
Salty:
Anterior sides and tip
of tongue Testing taste sensation
Bitter: Back of tongue
Normal: Abnormal:
Facial nerve intact; Asymmetrical or impaired
able to make faces. movement:
Taste sensation on - Nerve damage, such as that
caused by Bell’s palsy or stroke.
anterior tongue intact.
■ Impaired taste/loss of taste: -
Damage to facial nerve,
(Taste decreased in chemotherapy or radiation therapy
older adults.) to head and neck.
5. CN VIII—Acoustic Nerve
a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch close to patient’s
ear.
Testing CN IX and
X – motor function
c. Test sensory function of CN IX and motor function of CN
X by stimulating gag reflex.
- Tell patient that you are going to touch interior
throat
- then lightly touch tip of tongue blade to
posterior pharyngeal wall.
- Observe the pharyngeal movement.
Testing CN XII –
motor function
Normal: Abnormal:
Can protrude Asymmetrical/diminished/
tongue medially. absent movement/deviation
No atrophy, from midline/protruded tongue:
tumors, or - Peripheral nerve CN
lesions. XII damage.
■ Tongue paralysis results in
dysarthria.
Assessing Sensory Function
1. Light Touch
- Brush a light stimulus such as a cotton wisp over patient’s skin in
several locations, including torso and extremities.
Normal: Abnormal:
Identifies areas Diminished/absent cutaneous perception:
stimulated by light -Peripheral nerve damage or damage to
touch. posterior column of spinal cord.
- Peripheral neuropathies can also cause
sensory deficits.
■ Hypesthesia: Increased sensitivity.
■ Paresthesia: Numbness and tingling.
■ Anesthesia: Loss of sensation.
2. Pain
- Stimulate skin lightly with sharp and dull ends of toothpick/ paper
clip
-Apply stimuli randomly and ask patient to identify whether
sensation is sharp or dull.
-Touch patient’s skin with test tubes filled with hot or cold water.
-Apply stimuli randomly, and ask patient to identify whether
sensation is hot or cold.
Abnormal:
Normal: Diminished or absent pain perception:
Identifies areas - Peripheral nerve damage or damage to
stimulated and type lateral spinothalamic tract.
■ Hyperalgia:
of stimulation. Increased pain sensation.
■ Hypoalgesia:
Decreased pain sensation.
■ Analgesia: No pain sensation.
■ Diminished/absent temperature perception:
- Peripheral nerve damage or damage to
lateral spinothalamic tract
3. Vibration
-Place a vibrating tuning fork over a finger joint, and then over
a toe joint.
-Ask patient to tell you when vibration is felt and when it stops.
- If patient is unable to detect vibration, test proximal areas as
well.
Normal: Abnormal:
Diminished/absent vibration
Vibratory
sense:
sensation intact
- Peripheral nerve damage caused
bilaterally in
by alcoholism, diabetes, or damage
upper and lower
to posterior column of spinal cord.
extremities.
4. Kinesthetics (Position Sense)
-Determine patient’s ability to perceive passive movement of
extremities.
- Hold fingers on sides and move up and down, and have patient
identify direction of movement.
-Flex and extend patient’s big toe, and ask patient to describe
movement as up or down.
Normal: Abnormal:
Stereognosis intact ■ Abnormal findings suggest a
bilaterally. lesion or other disorder involving
sensory cortex or a disorder affecting
posterior
column.
6. Graphesthesia
- With patient’s eyes closed, use point of a closed
pen to trace a number on patient’s hand
- Ask patient to identify the number.
Normal: Abnormal:
Graphesthesia intact ■ Abnormal findings suggest lesion or
bilaterally. other disorder involving sensory corte
or disorder affecting posterior
column.
7. Two-Point Discrimination
Ability to differentiate between two points of
simultaneous stimulation.
- Using ends of two toothpicks/ paper clip,
stimulate two points on fingertips simultaneously.
- Gradually move toothpicks together, and assess
smallest distance at which patient can still
discriminate two points (minimal perceptible
distance).
- Document distance and location.
Normal: Abnormal:
Discriminates ■ Abnormal findings suggest lesion
between two points or other disorder involving sensory
on fingertips no cortex or disorder affecting
more than 0.5 cm posterior
column.
apart and on hands no
more than 2 cm apart.
8. Point Localization
■ Ability to sense and locate area being stimulated.
■ With patient’s eyes closed, touch an area; then have
patient point to where he or she was touched.
■ Test both sides and upper and lower extremities.
Normal: Abnormal:
Point localization Abnormal findings suggest lesion or
intact. other disorder involving sensory cortex
or disorder affecting posterior column.
REFLEXES
Documenting Reflex Findings
• Use these grading scales to rate the strength of each
reflex in a deep tendon and superficial reflex assessment.
Deep tendon reflex grades
0 absent
+ present but diminished
+ + normal
+ + + increased but not necessarily pathologic
+ + + + hyperactive or clonic (involuntary contraction
and relaxation of skeletal muscle)
Normal:
■ Contraction of biceps with flexion of forearm.
■ +2
b. Triceps Reflex
■ Abduct patient’s arm and flex it at the elbow.
■ Support the arm with your nondominant hand.
■ Strike triceps tendon about 1 to 2 inches above
olecranon process, approaching it from directly
behind.
Normal:
■ Contraction of triceps with extension at elbow.
■ +2
c. Patellar Reflex
■ Have patient sit with legs dangling.
■ Strike tendon directly below patella..
Normal:
■ Contraction of quadriceps with extension of
knee.
■+2
d. Achilles Reflex
■ Have patient lie supine or sit with one knee
flexed.
■ Holding patient’s foot slightly dorsiflexed,
strike Achilles tendon.
Normal:
■ Plantar flexion of foot.
■+2
e. Test for Ankle Clonus
■ If you get 4 reflexes while supporting leg
and foot, quickly dorsiflex foot.
Normal:
■ No contraction
Abnormal:
■ Absent/diminished DTRs:
- Degenerative disease; damage to peripheral nerve such as
peripheral neuropathy; lower motor neuron disorder, such
as ALS and Guillain-Barré syndrome.
■ Hyperactive reflexes with clonus:
- Spinal cord injuries, upper motor neuron disease such as
MS.
■ Rhythmic contraction of leg muscles and foot is positive
sign of clonus
- indicates upper motor neuron disorder.
2. Superficial Reflexes
a. Abdominal Reflex
■ Stroke patient’s abdomen diagonally from upper
and lower quadrants toward umbilicus.
■ Contraction of rectus abdominis. Umbilicus
moves toward stimulus.
b. Cremasteric Reflex
■ Gently stroke inner aspect of a male’s thigh.
Normal:
■ Testes rise.
c. Plantar Reflex (Babinski’s Response)
■ Stroke sole of patient’s foot in an arc from lateral
heel to medial ball.
Normal:
■ Flexion of all toes.
.
Assessing the Cerebellar Function
1. Balance tests
a. Gait
Observe as the person walks 10-20 feet, turns, and returns
to the starting point.
Normal:
Abnormal:
Person moves with a Stiff, immobile posture. Staggering or
sense of freedom. reeling. Wide base of support
Gait is smooth, rhythmic, Lack of arm swing or rigid arms
and effortless Unequal rhythm of steps. Slapping of foot.
Opposing arm swing is Scraping of toe of shoe
coordinated Ataxia – uncoordinated or unsteady gait.
The turns are smooth
Perform Tandem Walking
- ask the person to walk a straight line in a heel-
to-toe fashion.
This decreases the base of support and will
accentuate any problem with coordination.
Normal: Abnormal:
Person can walk Crooked line walk
straight and stay Widens base to maintain balance
balanced Staggering, reeling, loss of
balance
An ataxia that did not appear
now. Inability to tandem walk is
sensitive for an upper motor
neuron lesion, such as multiple
sclerosis.
b. The Romberg Test
(discussed previously)
Normal: Abnormal:
done with equal turning Lack of coordination
and quick rhythmic Dysdiadochokinesia
pace - Slow, clumsy, and sloppy
response
- occurs with cerebellar
disease
b. Finger-to-Finger test
With the persons eyes open, ask that he or she use index
finger to touch your finger, then his or her own nose.
After a few times move your finger to a different spot.
Normal: Abnormal:
Movement is smooth Dysmetria
and accurate - clumsy movement with
overshooting the mark
- occurs with cerebellar
disorder
Past-pointing
- constant deviation to one side
c. Finger-to-nose test
Ask the person to close the eyes and to stretch out the
arms.
Ask the person to touch the tip of his or her nose with
each index finger, alternating hands and increasing speed.
Normal: Abnormal:
Done with accurate Misses nose.
and smooth movement Worsening of coordination when
the eyes are closed
- occurs with cerebellar
disease
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